For The Providers of Youth Friendly Services

Transcription

1 For The Providers of Youth Friendly Services FAMILY PLANNING AND REPRODUCTIVE HEALTH

2 In July 2011, FHI became FHI 360. FHI 360 is a nonprofit human development organization dedicated to improving lives in lasting ways by advancing integrated, locally driven solutions. Our staff includes experts in health, education, nutrition, environment, economic development, civil society, gender, youth, research and technology creating a unique mix of capabilities to address today s interrelated development challenges. FHI 360 serves more than 60 countries, all 50 U.S. states and all U.S. territories. Visit us at

3 2008 UNFPA Egypt and Family Health International (FHI). All rights reserved. This document may be freely reviewed, quoted, reproduced or translated, in full or in part, provided the source is acknowledged. This document may not be sold or used in conjunction with commercial purposes.

4 Developed by: Dr.Magdy Khaled M.D. - Family Health International Consultant Technical Reviewers: Dr.Cherif Soliman- Family Health International Dr.Doaa Oraby- Family Health International 2

5 Acknowledgement Family Health International (FHI) and The United Nations Population Fund (UNFPA) are proud to present the Training Manual for Family Planning and Reproductive Health that aims to build the capacity of providers of youthfriendly services in Egypt. This comprehensive training manual includes facilitator guidelines, training slides and a CD-Rom of the PowerPoint slides. This activity is a fully collaborative effort between UNFPA and FHI in their efforts to enhance family planning and reproductive health services at the youth-friendly clinics. Thanks are due to the Egyptian Family Planning Association (EFPA) for their support in the development of this manual. Special gratitude is due to the facilitators who will use this manual in their work with service providers. We hope our efforts will assist them to have an immediate and long-lasting impact on the reproductive health and well-being of youth worldwide. Dr. Cherif Soliman Country Director FHI Egypt Dr. Faysal Abdel-Gadir Mohamed UNFPA Representative 3

6 Acronyms AIDS COCs ECPs EFPA FHI FGM FP HIV IPPF IUD POPs RH SRH STIs UN UNFPA VCT WHO YFS YFCs Acquired Immunodeficiency Syndrome Combined Oral Contraceptives Emergency Contraceptive Pills Egyptian Family Planning Association Family Health International Female Genital Mutilation Family Planning Human Immunodeficiency Virus International Planned Parenthood Federation Intra Uterine Device Progestin Only Pills Reproductive Health Sexual and Reproductive Health Sexually Transmitted Infections United Nations United Nations Population Fund Voluntary Counseling and Testing World Health Organization Youth Friendly Services Youth Friendly Clinics 4

7 Table of Contents Introduction 6 Facilitator's Guidelines 8 Session 1: Welcome and Introduction to the Workshop 9 Session 2: Youth Friendly Services 18 Session 3: Anatomy of the Female and Male Genital Organs 41 Session 4: Physiology of the Female and Male Reproductive Organs 68 Session 5: Family Planning Methods and Counseling 89 Session 6: Providing Sexual and Reproductive Health Information to Youth 161 Appendices Sample of Workshop Agenda Sample of Pre and Post-Tests Model Answer for the Pre and Post-Tests Final Workshop Evaluation 269 References 271 5

8 Introduction Youth represent a large, significant and growing demographic in Egypt. With generally low contraceptive use rates and knowledge about reproductive health, youth represent a relatively high proportion of the country's unmet reproductive health needs. Promoting comprehensive youth friendly services is essential in assisting youth to make responsible sexual and reproductive decisions and empowering them to enforce these decisions. Young People as an Age Group 1 Adolescents: years 2 Youth: years 3 Young people: years The meaning of "adolescence" -the period between 10 and 19 years of age- is understood in different ways in different cultural contexts. Almost universally, however, it is seen as a time of transition between childhood and adulthood, a period of physical and psychological changes associated with puberty, and of preparation for the roles, privileges and responsibilities of adulthood. The nature and experience of adolescence vary tremendously by sex, marital status, class, region and cultural context. As a group, however, adolescents are generally recognized to have sexual and reproductive health needs that differ from those of adults, and which are still poorly understood in much of the world. Adolescents and young people are at the beginning of their sexual and reproductive lives and they are also the next generation of parents. How they undergo preparation for this journey has tremendous implications for their own lives as well as for national reproductive health outcomes, including fertility, safe motherhood and sexually transmitted infections (STIs), particularly HIV/AIDS. Internationally, unmet need for family planning among adolescents is twice as high as among the adult population, despite undeniable risks: young women aged 15 to 19 are twice as likely as women in their twenties to die in childbirth, and of the 14 million teenagers who give birth each year world wide, many face serious pregnancy-related illnesses and at least 5 million undergo unsafe abortion. Purpose of this Training Manual This training manual is designed to assist in developing the capacity of the providers of youth friendly services (YFS) in providing family planning (FP) and reproductive health (RH) services and information to youth through a training workshop. YFS providers should be able to respond to the needs of young people, remove their fears, respect their concerns and provide the services within an environment that suit their preferences. The training content and methodology of this manual will enable YFS providers to 6

9 respond to the frequently asked questions by young people such as; body changes that occur at puberty, reproductive physiology and anatomy, virginity, the sexual response cycle in human beings, female genital mutilation, premarital counseling,pre and post natal care in addition to family planning. This training manual will be used to conduct a training workshop for physicians working in youth friendly clinics (YFCs). The training workshop goal, objectives, and expected outcomes are: Goal: To improve the quality of sexual and reproductive health (SRH) services provided in the youth friendly clinics. The Overall Objectives Are to: 1. Improve the family planning and reproductive health knowledge and skills of service providers 2. Strengthen the capacity of service providers in providing SRH information to youth Expected Outcomes: By the end of the training workshop, participants will be able to: 1. Explain the concept and components of YFS within the context of SRH 2. Describe the different parts and functions of the female and male genital organs 3. Explain the physiology of the female and male genital organs 4. Identify the appropriate family planning methods for youth according to their needs 5. Provide SRH information and services to youth according to their needs 7

10 Facilitator's Guidelines This training manual contains guidance for the facilitators to conduct each session in the form of session plans including: session title, objectives, allocated time, training methodology, materials, power point presentations and selected handouts. It is recommended that the facilitators will use interactive techniques to stimulate group thinking and active participation through a variety of training methods including brain storming, asking questions, group work and role-plays, which are included in this training manual. A set of power point slides are included for each session and will be given to the participants for self-learning. It is recommended that the organizers of this training workshop will ensure the availability of reference materials for reading during the workshop especially, "Family Planning A Global Handbook for Providers". It is also recommended that computers with internet access will be available during the session of "Providing SRH information to Youth" so that the participants will practice accessing selected web sites such as WHO, FHI, IPPF, UNFPA, Engender health and Pathfinder International for getting SRH information. This training workshop is designed to be implemented in four days but it could be adapted to a longer or shorter duration according to the needs, background and number of participants. The manual contains samples of Workshop Agenda (training schedule), Pre-Post Tests and Evaluation Forms. 8

11 Session one Welcome and Introduction to the Workshop

12 Session 1: Welcome and Introduction to the Workshop Allocated Time: (120 minutes) Session Objectives: By the end of this session, participants will be able to: 1. Describe the workshop goal, objectives, expected outcomes and agenda 2. Identify their expectations from the training workshop 3. Establish ground rules and group norms for the training workshop 4. List the names of facilitators and the participants 5. Answer the pre-test questionnaire Materials: Flipchart and Markers Overhead Projector and set of transparences OR Data Show and Power Point Presentations on a CD Presentation 1 Training agenda Name tags Index cards Adequate number of the pre-test copies Methodology: Step 1- Welcome (10 minutes) Host organizational staff welcomes participants as they arrive at the training room Ask each participant to sit in his/her designated space where his/her name tag has been placed Welcome the participants into the training room and introduce yourself and all facilitators to the trainees Step 2 - Introduction to the Workshop and the Participants (60 minutes) Distribute the pretest and ask participants to respond (20 minutes) Present the goal, objectives, expected outcomes, evaluation methodologies, and the agenda of the training workshop to the participants (10 minutes) Explore the participants training expectations and personal goals (15 minutes) Establish ground rules and group norms with participants and write it on a flipchart (15 minutes) 10

13 Appreciative Interview/Icebreaker (50 minutes) Give each one of the participants an index card and a marker and instruct them as follows: On the index card, participants should write down three of their own physical characteristics that are easily noticeable. Participants should not write their names Completed index cards will be given to the trainer Each participant is given a completed index card (but not his/her own) At this point, each participant carries out two activities: 1) S/he locates the person described on the index card; 2) S/he interviews the located participant and is in turn interviewed by him/her The interviewer then records the following information on the index card of the interviewed person 1. Name 2. Place of work 3. Two expectations of the workshop 4. Two thoughts regarding YFS Handouts 1. Workshop agenda 2. Workshop goal, objectives, and expected outcomes 11

14 Family Planning and Reproductive Health Training for the Providers of Youth Friendly Services 12

15 Goal To improve the quality of sexual and reproductive health (SRH) services provided in the youth friendly clinics (YFCs) 13

16 Objectives The overall objectives are to: Improve the family planning (FP) and reproductive health (RH) knowledge and skills of service providers Strengthen the capacity of service providers in providing SRH information and services to youth 14

17 Expected Outcomes By the end of the training workshop, participants will be able to: Explain the concept and components of YFS within the context of SRH Describe the different parts and functions of the female and male genital organs Explain the basic knowledge of the physiology of the female and male reproductive organs 15

18 Expected Outcomes (cont.) By the end of the training workshop, participants will be able to: Identify the appropriate FP methods for youth according to their needs Provide SRH information and services to youth according to their needs 16

19 Training Methods Working Groups Brainstorming Role Play Lectures with discussions Demonstration and re-demonstration 17

20 Session two Youth Friendly Services

21 Session 2: Youth Friendly Services Allocated Time: 180 minutes Session Objectives: By the end of this session, participants will be able to:- 1. Explain the concepts of Youth Friendly Services (YFS) 2. Explain characteristics of Youth Friendly Clinics (YFCs) 3. Identify the characteristics and qualifications of the providers of YFS 4. List strategies for implementing YFS Materials: Flipchart and Markers Overhead Projector and set of transparences OR Data Show and Power Point Presentations on a CD Presentation 2 Handout "Youth Friendly Services" Methodology: Step 1- Introduction to Youth Friendly Services (60 minutes) 1. Write the following on a flipchart 1 What are the issues that must be addressed in youth friendly services? 2 What are the needed providers' technical competencies? 2. Ask the participants to think about the listed questions 3. Divide the participants into two groups and instruct each group to go to a specific part of the room 4. Distribute a sheet of flipchart paper and marker to each group 5. Ask each group to answer one question 6. Give the working groups 20 minutes to discuss the question and to write the answer on the flipchart 7. Each group will then have 10 minutes to present what they have written on the flipchart 8. After each group presents, ask the participants to add their thoughts and suggestions Step 2- Characteristics of Youth Friendly Services (40 minutes) 1. Ask the participants about the characteristics of YFS 2. Write their responses on the flipchart 3. Present the 11 characteristics of Youth Friendly Services and refer to their thoughts on the flipchart when it is applicable. Step 3 Self-Assessment (60 minutes) 1. Divide the participants into two groups and instruct each group to go to a specific part of the room 2. Distribute a sheet of flipchart paper and marker to each group 19

22 3. Groups will then do self-assessment regarding what they are doing in their YFCs to identify gaps and suggest actions/recommendations for improvement - Group (1) work on the services and group (2) work on service providers 4. Give the working groups 20 minutes to discuss and write on the flipchart 5. Each group will then have 10 minutes to present what they have written on the flipchart 6. After each group presents, ask the participants to add their thoughts and suggestions Step 4 Wrap up/presentation (20 minutes) The facilitator will wrap up this session by using the power point presentation Handouts 1. YFS Handouts 2. Printout of the power point presentation 20

23 Handouts: Youth Friendly Services (YFS) Youth friendly services represent an approach, which brings together the qualities that young people demand, with the high standards that have to be achieved in the best public services. Such services are accessible, acceptable and appropriate for young people. They are in the right place, at the right time, at the right price (free where necessary) and delivered in the right style to be acceptable to young people. They are equitable because they are inclusive and do not discriminate against any sector of this young clientele on grounds of gender, ethnicity, religion, disability, social status or any other reason. Indeed, they reach out to those who are most vulnerable and those who lack services. The YFS are comprehensive in that they deliver an essential package of services to the whole target group. They are effective because trained and motivated health care providers who are technically competent and who know how to communicate with young people without being patronizing or judgmental deliver them. These providers are backed up by youth friendly support staff and have access to equipment, supplies and basic services. They also maintain a system of quality improvement so that staff are supported and re-motivated to keep up their high standards. Finally, the Youth Friendly Services are efficient so that they do not waste money, and they record enough information to be able to monitor and improve performance. The gold standard for Youth Friendly Services is that they are effective, safe and affordable; they meet the individual needs of young people who return when they need to and recommend these services to friends. Making services youth friendly is not primarily about setting up separate dedicated services, although the style of some facilities may change. The greatest benefit comes from improving generic health services in local communities and the competences of health care providers to deal effectively with youth. Service Providers Technical Competencies Doctors and nurses need good knowledge of normal adolescent development and the skills to diagnose and treat common conditions, such as anemia or menstrual disorders in girls, and to recognize signs of sexual or physical abuse. They need access to the correct drugs and supplies to treat common conditions and prevent health problems. They should know where to refer young people for specialized physical or psychological treatment. Such referrals may be to people or services outside the health system for counseling or social support. 21

24 Strategies for Implementing Youth Friendly Services 1. Service provider must see the person (the client) not the problem Technical competence must be accompanied by respect and sensitivity to draw the young person and discover underlying problems that may not be the immediate cause of a visit. By focusing on the person, rather than the symptom, providers can discover underlying concerns. Technical skills and a sympathetic professional approach should be combined with a non-judgmental approach. Health care providers do not need to abandon their own belief systems or values, but they do need to understand a situation from a youth s point of view and not to allow their own views to dominate the interaction. 1. Training and staff support Technically competent and empathetic staff need a system of ongoing support. A youth friendly approach should include repeated training sessions to refresh the skills of current staff as well as developing new skills for new staff. Training and peerreview sessions should cover everyone from doctors (who may believe they need no further training) to receptionist and support staff (who may be surprised that they are part of the team) as they may be the first person an adolescent meets at a health facility. If they are unfriendly, or judgmental he/she may never return. Management and supervision should be aimed at creating a supportive environment and at developing systems to maintain and improve quality. Health care providers should be involved in developing protocols and guidelines, covering key quality issues. They should also develop self-assessment and peer review mechanisms, which create a culture of openness. Monitoring systems should encourage young people to provide feedback on the services. 2. Making the services physically acceptable Services need to be provided in places that young people can reach and at times feasible to them. This may involve holding special clinics in youth centers, or other places where young people go. Clinical staff can take shifts to be available in late duty hours and weekends, when young people are not at school, college or working. Physical surroundings and clinic infrastructure are important. Many places have no special youth centre, but still provide a welcoming health facility. A busy city hospital with limited budget can create a YFS corner, by putting up a partition thus ensuring privacy, or by using a rear door where they can enter without being stigmatized. Some clinics give young people numbers when they arrive so that they can be called to see the doctor without having their names called out. Young people themselves may help to decide on a creative name that will be welcoming but not stigmatizing. Care must be given to the paintings, posters on the walls, cleanliness and availability of chairs in the waiting area. Additionally health promoting materials should be existing in the waiting area to be read or viewed by youth while waiting. 22

25 3. Confidentiality and privacy Youth need to be assured of privacy and confidentiality during consultation and afterwards. Young people should not be expected to undress or be examined where people can see them. Those waiting outside should not be able to hear a doctor giving a diagnosis. Additionally, patients must be assured that the medical records will not be left on view and that receptionists will not gossip. In most countries, there is legal obligation for doctors to report sexual assault and road traffic accident and there are also legal restrictions on treatment of young people below a certain age without parental consent. These and other legal constraints need to be explained as the only exceptions to a strict policy of confidentiality. This policy itself can be jointly developed with young people and health care providers so that everyone understands and feels comfortable with the ground rules. The confidentiality policy, including exceptions, needs to be explained to all young people and parents or guardians and to be clearly understood by referral agencies. 4. Services that are acceptable to the local communities Simply, making services youth friendly will not increase utilization, unless young people feel that it is acceptable to be seen using these services. Community support for the service must be sought. It should be made clear to the community members why youth friendly services are important and why these should include sexual and reproductive health and confidential counseling. Local meetings may be held for parents, and community and religious leaders should be approached for support. Services may even be located in community settings. There are many examples of services being delivered in schools, community centers or on the street. 5. Involving youth Services of high quality are those that closely involve youth in their planning and monitoring. The involvement of youth guarantees their right to have their views heard and also increases the confidence that other young people have in those services. Also, through involvement of young people, service providers can be confident that they are providing services in the right place, at the right time and in the right style. Characteristics of YFS YFS need to be accessible, equitable, acceptable, appropriate, comprehensive, effective and efficient. These characteristics are based on the WHO Global Consultation in 2001 and discussions at a WHO Expert Advisory Group in Geneva in They require: 1. Youth friendly policies that: Fulfil the rights of youth as outlined in the United Nations (UN) Convention on the Rights of the Child and other instruments and declarations Take into account the special needs of different sectors of the population, including vulnerable and under-served groups Do not restrict the provision of YFS on grounds of gender, disability, ethnic origin, religion or (unless strictly appropriate) age 23

26 Pay special attention to gender factors Guarantee privacy and confidentiality and promote autonomy so that youth can consent to their own treatment and care Ensure that services are either free or affordable by youth 2. Youth friendly procedures to facilitate: Easy and confidential registration of youth, and retrieval and storage of records Short waiting times and (where necessary) swift referral Consultation with or without an appointment 3. YFS providers who: Are technically competent in adolescent specific areas Offer health promotion, prevention, treatment and care relevant to each client s maturation and social circumstances Have interpersonal and communication skills Are motivated and supported Are non-judgmental, considerate, easy to relate to and trustworthy Devote adequate time to clients or patients Act for the best interests of their clients Treat all clients with equal care and respect Provide information and support to enable each client to make the right free choices for his or her unique needs 4. Youth friendly support staff who are: Understanding, considerate and treat each client with equal care and respect Competent, motivated and well supported 5. Youth friendly health facilities that: Provide a safe environment at a convenient location with an appealing ambience Have convenient working hours Offer privacy and avoid stigma Provide information and education material 6. Youth involvement, so that they are: Well informed about the services and their rights Encouraged to respect the rights of others Involved in service assessment and provision 7. Community involvement and dialogue to: Promote the value of health services Encourage parental and community support 24

27 8. Community based outreach and peer-to-peer services to increase coverage and accessibility 9. Appropriate and comprehensive services that: Address each client s physical, social and psychological health and development needs Provide a comprehensive package of health care and referral to other relevant services Avoid unnecessary procedures 10. Effective youth health services that: Are guided by evidence-based protocols and guidelines Have equipment, supplies and basic services necessary to deliver the comprehensive SRH package Have a process of quality improvement to create and maintain a culture of staff support. 11. Efficient youth services which have: A management information system including information on the cost of resources A system to make use of this information 25

28 Youth Friendly Services 26 26

29 Youth Friendly Services (YFS) What is it? Characteristics of YFS Characteristics of the providers and facilities Strategies for Implementing YFS 27 27

30 Definition YFS represent an approach which brings together the qualities that young people demand, with the high standards that have to be achieved in the best public services. YFS are: Accessible, acceptable and appropriate for youth In the right place, at the right time and at the right price Comprehensive because they deliver an essential package of services 28 28

31 Definition (cont.) Equitable and do not discriminate against any sector of youth on grounds of gender, ethnicity, religion, disability, social status or any other reason Reach out to those who are most vulnerable and those who lack services Effective because they are delivered by trained and motivated health care providers 29 29

32 Characteristics of Service Providers Well trained Demonstrate respect and concern for young people Knowledgeable of normal adolescent development Have the skills to diagnose and treat common conditions Have access to the correct drugs and supplies Know where to refer youth Respect the confidentiality and privacy 30 30

33 Strategies for Implementing YFS Service provider must see the person (the client) not the problem Training and staff support Making the service facilities acceptable Confidentiality and Privacy Services that are acceptable to the local communities Involving youth 31 31

34 Characteristics of YFS 1.Youth friendly policies that: Fulfil the rights Address the special needs of different sectors of the population Avoid discrimination Pay special attention to gender factors Guarantee privacy and confidentiality Ensure affordability to young people 32 32

35 Characteristics of YFS (cont.) 2. Youth friendly procedures to facilitate: Easy and confidential registration of clients, retrieval and storage of records Short waiting time and (where necessary) swift referral Consultation with or without an appointment 33 33

36 Characteristics of YFS (cont.) 3. Youth friendly health care providers who are: Technically competent Have interpersonal and communication skills Motivated and supported Non-judgmental Devote adequate time to clients or patients Provide information and support to enable adolescent s voluntary and informed choices 34 34

37 Characteristics of YFS (cont.) 4. Youth friendly support staff who are: Understanding and considerate, treating all youth clients with equal care and respect Competent, motivated and well supported 5. Youth friendly health facilities that: Provide a safe environment at a convenient location Have convenient working hours Offer privacy and avoid stigma Provide information and education material 35 35

38 Characteristics of YFS (cont.) 6. Youth involvement in planning, implementing and evaluating YFS so that they become: Well informed about the services and their rights Encouraged to respect the rights of others Involved in service assessment and provision 36 36

39 Characteristics of YFS (cont.) 7. Community involvement and dialogue to: Promote the value of SRH for youth Encourage parental and community support 8. Community based outreach and peer-to-peer services to increase coverage and accessibility 37 37

40 Characteristics of YFS (cont.) 9. Appropriate and comprehensive services that: Address each youth's physical, social and psychological health and development needs Provide a comprehensive package of SRH care and referral to other relevant services Do not carry out unnecessary procedures (i.e. doing unnecessary pelvic exam) 38 38

41 Characteristics of YFS (cont.) 10. Effective SRH services that are: Guided by evidence-based protocols Having equipment and supplies necessary to deliver the essential SRH package Having a process of quality improvement 39 39

42 Characteristics of YFS (cont.) 11. Efficient SRH services which have: Accurate data Monitoring and Evaluation System 40 40

43 Session Three Anatomy of the Female and Male Genital Organs

44 Session 3: Anatomy of the Female and Male Genital Organs Allocated Time: 120 minutes By the end of this session, participants will be able to: 1. List the different parts of the external and internal genital organs of female and male 2. Describe the functions of the different parts of the female and male genital organs Materials: Flipchart and Markers Overhead Projector and set of transparences OR Data Show and Power Point Presentations on a CD Presentation 3 Methodology: Exercise 1. (45 minutes) 1. Distribute the diagram of female external and internal genital organs and ask the participants to write down the names of the different parts 2. Ask two volunteers to present what they wrote for the external and internal organs to their colleagues 3. The facilitator will manage the discussion among the group and present the correct slides Exercise 2. (30 minutes) 1. Distribute the diagram of male external and internal genital organs and ask the participants to write down the names of the different parts 2. Ask a volunteer to present what he/she wrote for the external and internal organs to his colleagues 3. The facilitator will manage the discussion among the group and present the correct slides Exercise 3. (45 minutes) 1. Ask the participants to draw the female and male genital organs on flipcharts using their own drawing skills and inform them that the most appropriate drawings will be used by service providers to explain the reproductive anatomy to youth clients 2. Ask two volunteers to play the role of a service provider and a youth client who needs information about genital organs Handouts Printout of the power point presentation 42

45 Anatomy of the Female and Male Genital Organs 43 43

46 Female External Genital Organs Exercise

47 Female External Genital Organs (cont.) 45 45

48 Female External Genital Organs (cont.) A pad of fatty tissue over the pubic bone. This structure, which becomes covered with hair during puberty, protects the internal sexual and reproductive organs

49 Female External Genital Organs (cont.) Two spongy folds of skin - one on either side of the vaginal opening covering and protecting the genital structures

50 Female External Genital Organs (cont.) Two erectile folds of skin between the labia majora that extend from the clitoris on both sides of the urethral and vaginal openings

51 Female External Genital Organs (cont.) An erectile, hooded organ at the upper joining of the labia that contains a high concentration of nerve endings and is very sensitive to stimulation

52 Female External Genital Organs (cont.) The external opening of the urinary tract

53 Female External Genital Organs (cont.) A thin membrane that surrounds the opening to a young woman's vagina

54 Female External Genital Organs (cont.) The external opening of the genital tract

55 Internal Female Genitals Exercise

56 Internal Female Genitals (cont.) 54 54

57 Internal Female Genitals (cont.) Where ova develop and one is released every month

58 Internal Female Genitals (cont.) Where the fertilized ovum grows and develops into a fetus

59 Internal Female Genitals (cont.) An ovum travels along one of these tubes once a month, starting from the ovary Fertilization of the ovum (when sperm meets the ovum) occurs in the outer third of the tube 57 57

60 Internal Female Genitals (cont.) Join the outer sexual organs with the uterus

61 Internal Female Genitals (cont.) The lower portion of the uterus which extends into upper vagina Produces mucus 59 59

62 External and Internal Male Genitals Exercise

63 External and Internal Male Genitals (cont.) 61 61

64 External and Internal Male Genitals (cont.) Cylindrical structure with the capacity to be flaccid or erect Very sensitive to stimulation Glans penis is the most highly innervated part Penetrates the vagina during sex Provides passage for both urine and semen 62 62

65 External and Internal Male Genitals (cont.) A pouch of skin hanging directly under the penis and contains the testes Protects the testes and maintains the temperature necessary for the production of sperms 63 63

66 External and Internal Male Genitals (cont.) Paired, oval-shaped organs located in the scrotum Produce sperms and male sex hormone (testosterone) Highly innervated and sensitive to touch and pressure 64 64

67 External and Internal Male Genitals (cont.) Paired tubes that carry the mature sperms from the epididymis to the urethra

68 External and Internal Male Genitals (cont.) A pair of glandular sacs that secrete about 60% of the fluid that makes up the semen in which sperms are transported

69 External and Internal Male Genitals (cont.) Glandular structure that secretes some of the fluid that makes up the semen The alkaline quality of the fluid neutralizes the acidic environment of the male and female reproductive tracts 67 67

70 Session Four Physiology of the Female and Male Reproductive Organs

71 Session 4: Physiology of the Female and Male Reproductive Organs Allocated Time: 180 minutes By the end of this session, participants will be able to: 1. Describe the different phases of the menstrual cycle 2. Explain the processes of ovulation, conception and implantation 3. List the symptoms and signs of pregnancy 4. Explain the physiological functions of the male sex organs 5. Identify the risk of diseases and infections in relation to anatomy and physiology Materials: Flipchart and Markers Overhead Projector and set of transparences OR Data Show and Power Point Presentations on a CD Presentation 4 Handout "Reproductive Physiology" Methodology: Role play 1. (120 minutes) 1. Classify participant into FIVE groups and each group will select one participant to play the role of a service provider and one to play the role of a youth client 2. The five selected service providers will read the handouts of female reproductive physiology to get prepared to respond to the questions of their clients (20 minutes) 3. Each one of the selected youth clients will be assigned to ask one of the following questions: a. How menstruation occurs? b. How ovulation occurs? c. How conception occurs? d. How implantation occurs? e. What are the functions of the female sex hormones? 4. Each group will conduct their role play followed by discussion in 20 minutes Discussions (20 minutes) 1. The facilitator will ask the participants the following questions:- a. What are the symptoms and signs of pregnancy? b. What are the risks of diseases and infections in relation to the female anatomy and physiology Power point presentation (40 minutes) The facilitator will wrap up this session using the power point presentation Handouts 1. Reproductive Physiology Handouts 2. Printout of the power point presentation 69

72 Handouts: Reproductive Physiology Female Reproductive Physiology Female reproductive physiology is more complex than male reproductive physiology due to the cyclical nature of the reproductive system. 1. Ovaries: a. Produce ova (eggs) b. Produce estrogen and progesterone (in follicular cells) responsible for reproductive development of primary and secondary sex characteristics; sex drive; preparation of uterus for implantation and maintaining it during pregnancy and preparation of mammary glands for milk production by stimulating duct formation. 2. Fallopian tubes a. Receive ova upon ovulation b. Transport ova to uterus c. Site of fertilization 3. Uterus: Site of implantation of fertilized ovum and houses developing fetus 4. Vagina: Receives penis during copulation and serves as birth canal Menstrual Cycle Cycle that repeats at approximately one-month interval Menstruation: Periodic shedding of the inner layer of the uterus (endometrium) which is accompanied by bleeding Average menstrual cycle length is about 28 days; range days in the majority of women The cycle length can be influenced by stress, body composition, pregnancy, nursing, etc. Phases of Menstrual Cycle The phases of the menstrual cycle correspond to the ovarian cycle and the accompanying hormonal changes. They are 3 phases: 1. The menstrual and recovery phase: corresponds to the first three days of the ovarian cycle when the hormones are at their lowest levels and the primordial follicles are being stimulated to develop. The endometrium consists of the basal layer of endometrial stroma, the basal parts of the glands and the basal stumps of blood vessels. Following shedding of the epithelium (because of ischemia), the surface epithelium is regenerated from the epithelium lining the basal parts of the glands. 70

73 2. The estrogen or proliferative phase: increasing levels of estrogen secreted by the granulosa cells of the secondary follicle stimulates proliferation of the endometrium. The proliferative endometrium consists of: a. Columnar epithelium b. Tubular glands c. Cellular endometrial stroma d. Proliferating blood vessels 3. The progesterone or secretory phase: Following ovulation, secretion of progesterone by the corpus luteum stimulates the endometrium to become secretory, oedematous and vascular. The secretory endometrium is characterized by: a. Distended and secretory glands that have a serrated outline b. An oedematous stroma containing extracellular fluid c. Large, tortuous blood vessels The endometrium at this stage has all the necessary characteristics to receive a developing embryo. If fertilization occurs: 1. The oocyte undergoes division 2. The resulting zygote develops into a conceptus 3. Implantation occurs 5-6 days after fertilization Following implantation, the conceptus secretes Human Chorionic Gonadotrophin (HCG), which is very similar to LH and has similar effects. This causes the corpus luteum to continue to proliferate and to secrete increasing levels of progesterone so that the secretory endometrium is maintained. If fertilization does not occur: The secondary oocyte degenerates, HCG is not produced, the level of progesterone falls causing constriction of the endometrial blood vessels and ischemia of the endometrium, which is therefore not maintained and menstruation occurs. Ovulation The ovulation process is important if subsequent fertilization is to take place. This is a delicately timed phenomenon dependent on hormonal interactions involving a variety of endocrine glands. Conception In a fertile cycle, coitus around the time of ovulation will result in rapid entry of sperm through cervical mucus to the upper genital tract. Spermatozoa have been demonstrated in the fallopian tubes 5 minutes after ejaculation (although most sperm take considerably longer) and they can survive in the female genital tract for 5 days or more. 71

74 Fertilization Usually occurs within few hours of ovulation, in the outer third of the fallopian tube. After fertilization occurs, the ovum remains in the fallopian tube for about 72 hours. During this time, the fertilized ovum starts to divide in the lumen of the fallopian tube, resulting in a ball of cells called the morula. Implantation By day three after fertilization the morula (or developing embryo) reaches the uterine cavity. It takes another 2-3 days to start implanting and approximately another 3 days to implant successfully. On average, it takes 6 days after ovulation for the developing embryo to start implantation. Once the embryo is in the uterine cavity, the cells surrounding it start to produce HCG, which is detectable in maternal blood from the 8 th or 9 th day after ovulation. Completion of implantation is regarded as the point of conception. Many fertilized ova (about 50%) do not implant and are lost during the next menstrual flow. HCG maintains the corpus luteum, with continuing secretion of both progesterone and estrogen until the placenta takes over this function later in the pregnancy. Diagnosis of Pregnancy Most women suspect pregnancy before seeking confirmation. However, it is sometimes necessary to differentiate pregnancy from other causes of uterine enlargement and/or amenorrhea. The signs and symptoms of pregnancy are as follows: Cessation of menses (amenorrhea) Breast changes Vaginal discoloration Skin pigmentation Morning sickness Perception of fetal movements (quickening) Urinary frequency Fatigue Male Reproductive Physiology Testes: Produce sperms and testosterone Epididymis: Location of sperm maturation for motility and fertility, concentration and storage between ejaculations Vas Deferens: Stores and transports sperm Seminal Vesicles: Produce seminal fluid and secrete fructose to provide energy to sperms Prostate: Contributes alkaline secretions to seminal fluid, which neutralize the acidic vaginal secretions Penis: Copulation and urination Scrotum: Houses testes and provides temperature lower than the body for sperm maturation 72

75 Endocrine Regulation of Testicular Function: Hypothalamus Anterior Pituitary Testes GnRH LH & FSH Testosterone Risk of Diseases and Infections It is important to recognize that women are more vulnerable to diseases of the genital tract than men for some anatomical, physiological and histological causes: The lining of the vagina is a mucous membrane which is more permeable than the skin of the penis Women have more surface area through which infection can occur Lack of lubrication during intercourse and changes in the cervix during the menstrual cycle facilitate transmission of infection to women. Pre-pubertal girls and adolescents are particularly vulnerable, because their vaginal and cervical tissues may be less mature and more readily penetrated by organisms (e.g., Chlamydia and gonococci) Postmenopausal women are more vulnerable than younger women to get small abrasions in the vagina during sexual activity because of thinning and dryness of the tissues Women who have an STI (mostly asymptomatic unlike men) are more likely to get or transmit another STIs, including HIV/AIDS Other biological risks include the use of vaginal douches, which increase the risk of pelvic inflammatory disease 73

76 Reproductive Physiology 74

77 Endocrine Regulation of Ovarian Functions 75

78 Female Reproductive Physiology Ovaries: Produce ova (eggs) Produce sex hormones (estrogen and progesterone) responsible for: a. Reproductive development of primary and secondary sex characteristics b. Sex drive c. Preparing uterus for implantation and maintaining it during pregnancy d. Preparing mammary gland for milk production by stimulating duct formation 76

79 Female Reproductive Physiology (cont.) Uterus: Site of implantation of fertilized ovum and houses developing fetus Fallopian tubes: Receive secondary oocyte upon ovulation Transport ova to uterus Site of fertilization Vagina: Receives penis during copulation and serves as birth canal 77

80 Menstrual Cycle Menstruation: Periodic shedding of the inner layer of the uterus (endometrium) which is accompanied by bleeding Average menstrual cycle length - about 28 days (range days) in the majority of women 78

81 Ovarian Cycle 79

82 Endometrial Cycle 80

83 Ovulation Is important if subsequent fertilization is to take place A delicately timed phenomenon dependent on hormonal interactions and involving a variety of endocrine glands 81

84 Fertilization Following ovulation, the ovum is picked up by the fimbria of the fallopian tube The ovum remains viable for about 18 to 24 hour Fertilization occurs when the ovum meets a viable sperm 82

85 Implantation The fertilized ovum enters the uterine cavity The trophoblast cells burrow into the endometrium and implantation occurs 83

86 Diagnosis of Pregnancy The signs and symptoms of pregnancy are : Cessation of menses (amenorrhea) Breast changes Vaginal discoloration Skin pigmentation Morning sickness Perception of fetal movements (quickening) Urinary frequency Fatigue 84

87 Endocrine Regulation of Testicular Functions Hypothalamus Gn RH Testosterone Anterior Pituitary LH FSH Testes 85

88 Male Reproductive Physiology Penis: Copulation and urination Testes: Produce sperms and testosterone Epididymis: Location of sperms maturation, concentration and storage between ejaculations Vas Deferens: Stores and transports sperms 86

89 Male Reproductive Physiology Seminal Vesicles: Produce seminal fluid and secrete fructose to provide energy to sperms Prostate: Contributes alkaline secretions to seminal fluid which neutralize acidic vaginal secretions Scrotum: Houses testes and provides lower temperature for sperm maturation 87

90 Risk of Diseases and Infections Women are more vulnerable because: The lining of the vagina is a mucous membrane and more permeable than the outside of the penis More surface area through which infection can occur Changes in the cervix during the menstrual cycle Use of vaginal douches, which increase the risk of inflammatory disease 88

91 Session Five Family Planning Methods and Counseling

92 Session 5: Family Planning Methods and Counseling Allocated time: (300 minutes) By the end of this session, participants will be able to, 1- Define the main components of SRH counseling 2- List the different categories of family planning (FP) methods 3- Practice utilization of the WHO eligibility criteria for using the different FP methods 4- Identify the appropriate FP methods for youth/young people 5- Describe the emergency contraceptive methods 6- Demonstrate putting on the male condom on penile model Materials: Flipchart and Markers Overhead Projector and set of transparences OR Data Show and Power Point Presentations on a CD Presentation 5 Family Planning A Global Handbook for Providers Pelvic model and IUD insertion instrument Penile model and male condom Methodology Role play 2 (40 minutes) The trainer will ask for (3) pairs of volunteers from the participants to play the role of (3) youth clients asking for contraceptive advice and (3) service providers giving the advice regarding the use of three different FP methods (combined oral contraceptive pills (COCs) - male condom emergency contraception) The participants will observe the (3) role-plays, take notes and get involved in an interactive discussion (10 minutes for each) The facilitator will moderate the discussion around the (3) role-plays focusing on the following points: (10 minutes) a. Fears and concerns of the youth clients b. Communication skills of the service providers c. The ability of the providers to convey the accurate information d. Satisfaction of the clients Group work 1 (60 minutes) The facilitator will ask the participants to be divided into (5) groups Each group will prepare a short presentation on flip chart after reading the handouts of SRH counseling (20 minutes) Each group will have (5 minutes) to present and the facilitator will wrap up in (15 minutes) 90

93 The (5) topics of the presentations are: 1. What is counseling? 2. How will counseling help the clients? 3. What are the tasks that are addressed in SRH counseling? 4. Who can do counseling? 5. Contraceptive counseling Discussion (20 minutes) The facilitator will: Ask the participants to list the different FP methods Write down the methods on the flipchart Then ask the participants to categorize them (hormonal, mechanical etc ) Group work 2 (80 minutes) The facilitator will distribute (Family Planning A Global Handbook for Providers) to all participants and ask them to be divided into 5 groups and each group will read one of the following sections (30 minutes) Group 1. Hormonal contraception Group 2. Intra Uterine Device Group 3. Local barriers Group 4. Natural methods Group 5. Emergency contraception and surgical methods The facilitator will then ask each group a set of questions to be answered by the different members of the group in an interactive way and allow the rest of the groups to participate in the discussion and write the answers on the flip chart Questions for group 1: (10 minutes) 1. What are the hormonal methods? 2. What is the mode of action of each method? 3. How to use each method? 4. what are the advantages? 5. What are the common side effects? Questions for group 2: (10 minutes) 1. How do IUDs prevent pregnancy? 2. What are the main counseling points for using this method? 3. Explain the insertion procedures on a pelvic model Questions for Group 3: (10 minutes) 1. Demonstrate using a male condom to a client using the penile model 2. Explain the advantages of male and female condoms 3. Explain the mechanisms of action of a local spermicide and how to use it 4. What is the diaphragm? 91